Science You Can Use: Before you pop in that pacifier, take a closer look at this study.

Written by Tanya Lieberman, IBCLC

Earlier this month the topic of pacifiers and breastfeeding was all over the news. At least 85 articles ran in print and online publications about it.

The big news? Researchers from the Oregon Health & Science University (OHSU) reported a decline in exclusive breastfeeding and an increase in formula supplementation when pacifiers were banned as part of a hospital’s effort to become Baby Friendly.

Since this seemed to contradict other research, and since it had gotten so much press that sooner or later I’d get asked about it by my in-laws, it seemed like a good idea to take a closer look.

After all, as I’d written in this Booby Traps post, pacifiers have long been viewed as detrimental to breastfeeding. So much so that “giving no artificial teats or pacifiers to breastfeeding infants” is one of the evidence-based Ten Steps to Successful Breastfeeding, and the American Academy of Pediatrics (AAP) in their breastfeeding policy, says: “Pacifier use is best avoided during the initiation of breastfeeding and used only after breastfeeding is well established.” Despite this, the CDC reports that only 30% of hospitals limit the use of pacifiers so that less than 10% of healthy full-term breastfed infants are given pacifiers by maternity care staff members.

So, what exactly is this study? It is a retrospective, observational look at exclusive breastfeeding and formula supplementation at one hospital which eliminated pacifiers as part of an effort to become Baby Friendly. It examined feeding records of 2,249 infants born between June 2010 and August 2011.

Three things stood out for me as I learned more about the research, none of which got a whole lot of attention in the press reports:

1) This research was being presented at a conference but and is preliminary and unpublished, which means that it hasn’t been peer reviewed by experts in the field. This type of research is not considered as rigorous as methods like randomized controlled trials.

2) As Dr. Richard Schanler, chair of the American Academy of Pediatrics‘ breast-feeding section pointed out, “the study did not offer information about how newborns were comforted who did not receive pacifiers or how hospital staff members were educated about this issue during the research” adding “you cannot draw conclusions to change health care practices from this type of study.” As Miriam Labbok pointed out, if pacifiers were removed without parents being taught other methods of soothing babies, is it that surprising that parents would reach for a bottle?

3) The authors themselves discourage the conclusion that limiting pacifier use harms breastfeeding. One of the study’s authors states: “We view this as an interesting observation, but we do not claim a cause and effect relationship. Our goal in publicizing this data is to stimulate dialogue and scientific inquiry into the relationship between pacifiers and breastfeeding.” [emphasis mine]

What does the other research on this topic say?

This topic has been investigated quite a bit, so there is a decent body of research to look at. A meta-analysis of 29 studies studies on this topic found the following:

The 4 randomized controlled trials revealed no difference in breastfeeding outcomes with different pacifier interventions

Most of the 25 observational studies reported an association between pacifier use and shortened duration of breastfeeding.

In other words (mine), the evidence is mixed, with an suggestion, unconfirmed in rigorous research, that pacifiers have an effect on breastfeeding.

To bink, or not to bink?

Ever heard of the “precautionary principle?” This is a term from the environmental movement which (to paraphrase significantly) means that if an action carries a suspected risk of causing harm, in the absence of scientific consensus that the action causes harm, you don’t do it.

Since the evidence is mixed, the safest course of action is to proceed with caution. Will your baby – and breastfeeding – be affected if you give your baby a pacifier? We can’t say for certain. But since at least some of the evidence supports a risk, it’s best to avoid it (as the AAP says) until breastfeeding is well established.

And in the meantime, learn the fine art of soothing a baby without a pacifier or bottle, starting of course with plenty of breastfeeding and skin-to-skin time! Holding, babywearing, and motion go a long way to…yes, keeping the binkie at bay.

Did you use a pacifier? Did it have any effect on your breastfeeding experience? What did you think of this study?

7 Responses to Science You Can Use: Before you pop in that pacifier, take a closer look at this study.

I was adamant about NOT using artificial nipples of any kind for the first month of our daughter’s life. On difficult nights, she sucked on daddy’s pinky. The good news? Our daughter doesn’t take a pacifier. The bad news? Our daughter doesn’t take a pacifier. Ha! No, in all honesty, I’m glad she doesn’t, but every now and then, I wish she would. Fortunately, we’re approaching the one year mark and the need for one is almost completely gone. And, we’re still breastfeeding!!!

One thing that bothered me in most of this research is that they were so busy talking about “nipple confusion” or “no nipple confusion”, that they failed to focus on one of the main reasons a pacifier isn’t suggested… if a baby is sucking on ANYTHING on those first few crucial days of life, it should be mom! All of that stimulation is what helps the mother’s milk to come in! So many mothers feel they “don’t have enough” or “aren’t making enough milk fast enough”. There is no better way to encourage those moms who want to see their milk come in than to tell them all of that sucking is doing just that!

My son was born with a great latch and super hungry. After my milk came in and I saw he was gaining weight, I introduced a paci to help with those few times (for me, doctor appointments and car travel) when I just couldn’t whip out a boob. I think he used the paci a bit from about 1 week until 10 weeks and then voluntarily gave it up. He continued to breastfeed on demand until self weaned at almost 2 years old. I don’t think it had any negative impact on his nursing, and certainly helped keep him calm during those hectic times when it wasn’t safe or feasible to nurse.

Ds took a paci for the first maybe 3/4 months, then wouldn’t anymore. I sometimes wish he wouldn’t have stopped,but better then than later I suppose! Our breastfeeding relationship was/is flawless. ( he is 2.5 and still nursing)
My DD, n the other hand, will not take a paci. I’ve tried so many. But she doesn’t really need it, I just wanted it for car. She hates car rides. She won’t take pinky either. She nurses great.
All in all, I dont think babies need them, although they are nice when mom is feeling lazy and just wants baby to be quiet!! 🙂

I just want to point out that while the information is mixed, Randomized Controlled Trials are much better pieces of evidence than observational trials, because there are so many potentially confounding factors. They are able to determine causality when observational studies can’t. I really think that you ought to have quoted the conclusion of the review you cited, “The highest level of evidence does not support an adverse relationship between pacifier use and breastfeeding duration or exclusivity. The association between shortened duration of breastfeeding and pacifier use in observational studies likely reflects a number of other complex factors, such as breastfeeding difficulties or intent to wean.”

So the BEST evidence does not show a causal link between pacifier use and a shortened duration of breastfeeding, and the observational link between pacifier using and early weaning is probably due to recall bias, different intentions, or other factors. Given the evidence is against a causal link, it doesn’t make sense to focus on avoiding pacifiers as an important part of promoting breastfeeding.

My 1st born was exclusively breastfed until he was a year old and we did breastfeeding on-demand. He continued to nurse after he started eating solids until he weaned at age 2. BUT he loved his pacifier too! Sucking is a soothing thing for babies. If he wasn’t hungry then he didn’t want to nurse or if I wasn’t there it was great that he had the comfort of his pacifier. So when baby number two came along I just assumed thing would be the same (silly I know since these are 2 different people) but baby brother wants nothing to do with a pacifier and instead likes his thumb. I have tried to get him to nurse instead when I notice he does this but like big brother he refuses to if he’s not hungry. Again- sucking is a comfort thing. Whether it is the breast, pacifier, thumb, a toy, or blanket it’s not unnatural for a baby to want to suck when they aren’t hungry. And every baby is different. Parents need to do what is best for their baby but don’t stress if it doesn’t go exactly as you planned! Just enjoy every second with your unique bundle of joy 🙂

My first is 3 months old. I have been giving him pacifiers as a way to sooth him since day one. He loves them! He is exclusively breastfed and has no issues latching or nursing at all. I guess its up to the individual, but using a pacifier had saved my sanity and keep my little man happy. I would recommend them.